<html>
    <head>
        <meta http-equiv="Content-Type" content="text/html; charset=iso-8859-1" />
        <title>patient registration</title>
        <link href="style.css" rel="stylesheet" type="text/css" />
        <link href="calendar.css" rel="stylesheet" type="text/css" />
        <link href="validate.css" rel="stylesheet" type="text/css" />
        <script src="calendar.js" ></script>
        <script src="validate.js"></script>
        <script src="ajaxscript.js" ></script>
    </head>

    <body>
        <div id="header"></div>
        <div id="navigation"><ul>
                <li><a href="#">Home</a></li>
                <li><a href="register.html">Registration</a></li>
                <li><a href="#">Products</a></li>
                <li><a href="#">Services</a></li>
                <li><a href="#">Contact us</a></li>
            </ul></div>
    <center><br><font size="7">Patient Registration Form</font>
        <form name="pregister" id="pregister" method="post" onsubmit="return validate(this)" action="./patient">
            <table border="0" style="background:#669d37">
                <tr> 
                    <td> <font size="4"><b><font color="red">*</font>PatientName </b></font> </td> 
                    <td><input  type="text" name="pname" id="pname" /></td>
                    <td rowspan="2"><img src="" height="130" width="120">	</td>
                </tr>			

                <tr> 
                    <td> <font size="4"><b><font color="red">*</font>FatherName </b></font> </td> 
                    <td><input  type="text" name="fname" id="fname" /></td>
                </tr>


                <tr> 
                    <td> <font size="4"><b><font color="red">*</font>Gender </b></font> </td> </tr>
                <tr>
                    <td>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 
                        <strong><input type="radio" name="gender" id="gender" value="male" checked/>male</strong></td>
                    <td>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
                        <strong><input type="radio" name="gender" value="female" id="gender"/>female</strong></td>
                </tr>


                <tr> 
                    <td> <font size="4"><b><font color="red">*</font>DOB </b></font> </td> 
                    <td><a name="a"><input  type="text" name="dob" readonly="readonly" /></a></td>			 
                    <td> <a href="#a" onClick="setYears(2012,2012); showCalender(this, 'dob');">
                            <img src="calender.png" /></a>   


                        <table id="calenderTable">
                            <tbody id="calenderTableHead">
                                <tr>
                                    <td colspan="4" align="center">
                                        <select onChange="showCalenderBody(createCalender(document.getElementById('selectYear').value,this.selectedIndex, false));" id="selectMonth">
                                            <option value="0">Jan</option>
                                            <option value="1">Feb</option>
                                            <option value="2">Mar</option>
                                            <option value="3">Apr</option>
                                            <option value="4">May</option>
                                            <option value="5">Jun</option>
                                            <option value="6">Jul</option>
                                            <option value="7">Aug</option>
                                            <option value="8">Sep</option>
                                            <option value="9">Oct</option>
                                            <option value="10">Nov</option>
                                            <option value="11">Dec</option>
                                        </select>
                                    </td>
                                    <td colspan="2" align="center">
                                        <select onChange="showCalenderBody(createCalender(this.value, 
                                                        document.getElementById('selectMonth').selectedIndex, false));" id="selectYear">
                                             <option value="1">1985</option><option value="2">1986</option><option value="3">1987</option>
                                            <option value="4">1988</option><option value="5">1989</option><option value="6">2000</option>
                                            <option value="7">2001</option><option value="8">2002</option><option value="9">2003</option>
                                            <option value="10">2004</option><option value="11">2005</option><option value="12">2006</option>
                                            <option value="13">2007</option><option value="14">2008</option><option value="15">2009</option>
                                            <option value="16">2010</option><option value="17">2011</option>
                                           
                                        </select>
                                    </td>
                                    <td align="center">
                                        <a href="#a" onClick="closeCalender();"><font color="#003333" size="+1">X</font></a>
                                    </td>
                                </tr>
                            </tbody>
                            <tbody id="calenderTableDays">
                                <tr style="">
                                    <td>Sun</td><td>Mon</td><td>Tue</td><td>Wed</td><td>Thu</td><td>Fri</td><td>Sat</td>
                                </tr>
                            </tbody>
                            <tbody id="calender"></tbody>
                        </table>
                    </td>

                </tr>



                <tr> <td> <font size="4"><b><font color="red">*</font>username </b></font> </td> 
                    <td><input  type="text" name="username" id="username" onblur="checkuser();"/></td>
                    <td><div id="id1">Please enter user name</div></tr>


                <tr> <td> <font size="4"><b><font color="red">*</font>Password</b></font></td> 
                    <td><input  type="password" name="password" id="password"/></td>
                </tr> 

                <tr> <td> <font size="4"><b><font color="red">*</font>Re-enter Password </b></font> </td> 
                    <td><input  type="password" name="repassword" id="repassword"/></td></tr>
                <tr>
                    <td> <font size="4"><b><font color="red">*</font>Address</b></font></td>
                    <td><textarea rows=5 cols=15 name="address" id="address" ></textarea></td>
                </tr>
                <tr> <td> <font size="4"><b><font color="red">*</font>EmailId </b></font> </td> 
                    <td><input  type="text" name="email" id="email" maxlength="50"/></td></tr>
                <tr> <td> </td><td> </td></tr>

                <tr> <td> <font size="4"><b><font color="red">*</font>Contact no . </b></font> </td> 
                    <td><input  type="text" name="mobile" id="mobile" maxlength="13"/></td></tr>
                <tr> <td> </td><td> </td></tr>               

                <tr> 
                    <td><font size="4"><b><font color="red">*</font>Martial Status </b></font> </td>
                    <td><select name="status">
                            <option ><b><font size="4">----please select----</font></b></option>
                            <option value="married"><b><font size="4">married</font></b></option>
                            <option value="Not Married"><b><font size="4">Not Married</font></b></option>
                        </select></td>
                </tr>	
                <tr>
                    <td><font size="4"><b>Image </b></font></td>
                    <td><input type="file" name="image" style="width:2px"/></td>
                </tr>

                <tr>
                    <td>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
                        &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</td>

                    <td><input type="submit" name="register" value="Register" style="width:100px;margin-top:50px" /></td>
                </tr>			

            </table>
        </form>
    </center>
</body>
</html>

